MUSC Electronic Medical Record Update October 2004 Clinical

1

• MUSC
• Electronic Medical Record Update
• October 2004

2
Clinical System Initiatives

• PMSI/Practice Partner Overview and Status
• Other Clinical System Initiatives
• Information Technology Governance Structure

3
PMSI/Practice Partner Features

• Goal Paperless outpatient chart.
• Types of entry functions
• Vitals, problem list, allergies
• Phone requests documented
• Meds/prescription (and re-fill) writer
• Clinic notes (can be transcribed or entered via
  point and click templates)
• Scanning capability (referring or lose documents)
• Other types of data available
• Lab and radiology results
• Hospital transcription such as Discharge
  Summaries and Operative Reports

4
Practice Partner Implementation Objectives

• Enhance patient safety (e.g., PP has a
  prescription writing tool that has drug
  interaction and allergy checking features).
• Improve documentation quality in order to better
  address regulatory, legal, and MUSC guidelines.
• Improve coordination of care via secure
  electronic storage of clinical documentation such
  as vital signs, clinic notes, medications,
  problem lists, allergies, and phone calls.
• Enhance revenue by improved workflow
  efficiencies, decreased turnaround time for
  documentation and availability of clinical
  documentation for billing purposes.
• Reduce the costs of medical records storage,
  filing space, transcription costs and records
  management.
• Decrease time spent with call backs from patients
  and pharmacies.

5
Practice Partner Transcription Options

• Dictation options
• Transcriptionist can type directly into PP, after
  selecting the patient in PP. The Word processing
  function within PP has spell check and allows
  for templates to be built (e.g., standard
  headings, sections, etc.). This PP tool also
  allows for easy import of meds lists and other
  data into the note that is available within PP
  (and vice-versa).
• Transcriptionist types in MS/Word (with some
  required standard codes at the top of the Word
  document) - and then imports these documents into
  PP and selecting a note import function. This
  import can be done in batches.
• Physician direct entry options
• Physician types directly into PP using the word
  processing function as described in 1A above.
• Physician enters notes via pre-formatted
  templates that are typically developed for the
  type of diagnosis or type of visit. Each
  specialty usually creates/refines these templates
  over time.
• Note PP does not currently have bold, italics,
  etc. capabilities in the current version, but a
  new version that has these features will be
  implemented by the end of 2004.

6
PMSIs Practice Partner (PP) system Status/Plans

• Goal 330 attending physicians on PP by end of
  2005.
• For each physician, there are many additional
  users that are activated (e.g., nurses, COM
  staff, billing personnel).
• Approx. 120 physicians currently using PP.
• Approx. 50 in process (beginning with nurses)
  thru 12/31/2004.
• Remaining 160 physicians to be implemented in
  2005.
• Two Oracle data bases to be merged into one
  (November)
• System/server redundancy planned for December.
• Supported by Ambulatory IS team led by Jim Smith
  (5 FTEs).

7
Practice Partner Current Status

• Currently Utilizing Practice Partner
• Family Medicine 23
• Endocrinology 18
• Internal Medicine (partial) 27
• Neurosurgery 5
• OB/GYN 27
• General Pediatrics 10
• Pediatrics (others) 10
• Plastic Surgery 4
• 124
• In Process
• Neurology 13
• Rheumatology 8
• Ortho adult 11
• Pulmonary 13
• Peds surgery 2
• 47

8
Practice Partner Rollout Plan

• 2005 Rollout (yet to be scheduled)
• Cardiology 22
• Dermatology 6
• HemOnc 14
• Infectious Diseases 6
• ENT 19
• Nephrology 15
• Ophthalmology 17
• Peds Adolescent Med 2
• Peds Cardiology 11
• Peds HemOnc 4
• Peds Nephrology 2
• Peds Neonatology 11
• Peds Pulmonary 4
• Surgery 22
• Urology 6
• Total 2005 161

9
Other Clinical System Initiatives

• Advanced Point of Care Clinical System (RFP)
• OR system replacement
• Reinitiated in July (i.e., vendor selection to
  replace SurgiServe).
• Site visits in progress.
• Transplant system
• Reinitiated in May (RFP process...).
• Intent to award to be announced this week.
• C3 project (Oacis)
• Computerized Clinical Charting (C3).
• Pilot for inpatient nursing documentation on
  wireless (laptop!?) LYNX DAL COWs scheduled for
  mid November.
• Web front-end to Oacis in early 2005.

10
IT Governance Committees

11
OCIO Team